Cancer: Mental Trauma and Care Dr. Anwar Hossain MD Thesis Part Student Dept. of Medical Oncology NICRH, Dhaka.

Introduction: The sound cancer mostly creates a panic environment & bites the nerves of the person, nerves of the family as well as the nerves of the surrounding society. . It breaks the physical, psychological, social, financial as well as spiritual equilibrium of the person. Along with the physical and psycological problems of cancer patients their care givers also go through some degree of psychological difficulties.

Impact of cancer: At diagnosis – around 50% have depression/anxiety severe enough to impact negatively on their daily lives. About 25% continue to experience distress during the following 6 months. About (10-15)% experience symptoms severe enough to warrant intervention by superspecialists. < 10% detected by hospital staff If undetected = untreated = could progress to severe psychiatric illness.

Common psychiatric disorders associated with cancer: Anxiety disorders: Most common psychiatric morbidity for the cancer patients is the anxiety disorders. Among anxiety disorders, generalized anxiety disorders, phobic disorder, panic disorder, panic attack or disorder, mixed anxiety and deressive disorder may be found.

Continued… Depressive Disorders: About 25% of the patients suffer from Depressive disorders. Reviews showed the prevalence of depression ranges from 3-69% among the cancer patients.

Continued… Adjustment disorders: About 20% of the cancer patients suffer from adjustment disorders as the disease breaks the existing equilibrium in all aspects of the patients as well as the family members.

Continued… Suicide: Suicidal rate is five times more common in cancer patients than normal population and 50% suicide occurs in those who are clinically depressed.

Continued… Other psychiatric disorders: Affective(mood) disorders Somatoform disorders Substance misuse Personality and behavioural disorders Schizophrenia Organic Disorders etc

Reaction to bad news: Elisabeth Kubler-Ross, a psychiatrist , made a comprehensive and useful organization of reactions to impending death: Stage 1: Shock and denial Stage 2: Anger Stage 3: Bargaining Stage 4: Depression Stage 5: Acceptance

Response to this reaction: When breaking any serious illness or bad news to the patient, diplomacy and compassion should be guiding principles. Doctors, however, should ask patients how much they want to know because some persons do not want to know all the facts about their illness and physicians should be encouraging and answering questions from patients.

Continued… Telling the Truth… Physicians, however, should not hide the truth so that patients may take part in their decision of the terminal care services along with the family members. SPIKES Protocol can be used to break the bad news: S- Setting up the interview

Continued… P- Assessing the patient’s Perception I - Obtaining the patients Invitation K- Giving Knowledge and information to the patient E- Addressing patient’s Emotions and Empathic response. S- Strategy and summery

Taking Care: Holistic care of cancer patients: This starts with relieving the physical symptoms, minimizing the psychological discomforts, increasing the social support by ensuring appropriate use of all available facilities.

Continued… Depression Anxiety and Stress Most often s/s of these disorders are overlapping. Depressed mood Loss of interest(Anhedonia) Fatigue Loss of libido Sleep disturbence Lack of concentration Irritability

Continued… Fear of impending disaster Suicidal thinking or attempt. Somatic symptom like pain headache tremor fits and weakness. Five or more for depression and three or more for anxiety.

Continued… Mini-mental state examination(MMSE) can be used to asses the extend cognition. Orientation to time- 5 points Orientation to place- 5 points Registration-3points Attention and calculation- 5 points Recall- 3 points Language- 2 points

Continued… Complex command- 6 points Repetation- 1 point Total=30 points 24-30= normal cognition 19-23= mild impairment 10-18= moderate impairment 9 or less= severe impairment

Management: Psycological treatment: Explanation Reassurence Providing information regarding the disease Rehabilitation Psychotherapy

Continued… Biological or pharmacological treatment- In management of depression & anxiety pharmacological agents also overlaps. Short term Benzodiazepines –clonazepam lorazepam diazepam Beta adrenoreceptor antagonist- propranolol.

Continued… Long term with antidepressant drugs: Tricyclics- amitryptyline, nortryptyline SSRI-Setraline, fluoxetine MAOI- Phenelzine NSSRI- duloxetine, mirtazapine Both short & long term agents should be started simultaneously from the beginning.

Continued… Sometimes if any psychotic or abnormal behaviour is seen antipsychotic drugs (Chlorpromazine, Haloperidol, Risperidone, Quetiapine) may be used. Duration of treatment is at least 6-9 months after recovery.

When to refer to psychiatrist? Severe anxiety or depression which may cause suicidal thoughts or attempts. Resistant or poor response to treatment. Psychotic or abnormal behaviour like hallucination, dellution, illution etc.

Take home message: Every cancer patient suffers from some degree of psychiatric illness & this should not be overlooked. Should be assesed rationally. And has to be treated simultaneously with other primary modalities of cancer treatment for better outcomes.

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